Introductory article to İkİIşik H, Sezerol MA, Taşçı Y, et alCOVID-19 vaccine hesitancy and related factors among primary healthcare workers in a district of Istanbul: a cross-sectional study from TurkeyFamily Medicine and Community Health 2022;10:e001430. doi: 10.1136/fmch-2021-001430
Vaccination is an important weapon in the fight against the pandemic and is one of the most effective ways to control infectious diseases . Primary health care workers are a critical component of immunization services, a part of preventive health services. As unarguably the most intense advocates of vaccine-preventable diseases, they are often the first place of reference for both childhood and adult vaccinations. Family physicians and family health workers, considered reliable sources of vaccine information, have a unique position where individuals in rural and urban areas can access frequently, uninterruptedly, cheaply, and easily . Thanks to these positions, they have a great role in reducing all kinds of vaccine hesitations and establishing confidence in the vaccine in their dependent population .
Family health centers are the facilities where the vaccination intention is much more vital, as they carry out the contact and case follow-ups during the pandemic and are the center of vaccination application. Hence, we conducted this study to determine the risk perceptions of primary care workers for COVID-19 vaccines and the predictive factors in their willingness to have the COVID-19 vaccine before vaccination, which started on January 14, 2021, in Turkey.
The cross-sectional study was conducted on family physicians and family health staff working in primary care family health centers in Üsküdar district of Istanbul with a population of 520,771 between 25-29 December 2020 . There are 44 family health centers, including 158 family physicians and 165 family health workers working in the district.
A sample was not selected as it was aimed to reach all 323 people working in family health centers in the district. Two hundred seventy-six of the healthcare professionals were reached (response rate: 85.4%). The survey was prepared by using Google Forms, and the generated web-based questionnaire link was shared onlinewith all family health center staff.
Statistical significance level was accepted as p<0.05. All analyzes were performed with IBM SPSS statistics 22.0. This study was approved by the The Ethics Committee (Ethics Committee No: dated 23.12.2020 and decree no 213).
54.3% (n=150) of the respondents were midwives/nurses and 45.7% (n=126) were physicians. The mean age of the participants was 38.6±10.3 (min.21; max.62), and 82.6% (n= 228) were women. While 50.4% (n=139) of family health center employees agree to have the COVID-19 vaccine approved by the Ministry of Health, 20.7% (n=57) refused the COVID-19 vaccine. 29% (n=86) of the participants were undecided about getting vaccinated. Univariate relationships between COVID-19 vaccination intention and sociodemographic variables are shown in Table 1.
Table 1. Perception of risk and vaccination intention by demographic characteristics
|n (%)||n (%)||n (%)||n (%)|
|midwife/nurse||56 (37.3)||50 (33.3)||44 (29.3)||150 (54.3)||p<0.001|
|Doctor||83 (65.9)||30 (23.8)||13 (10.3)||126 (45.7)|
|Below 40 years of age||69 (42.6)||48 (29.6)||45 (27.8)||162 (58.7)||p=0.001|
|40 years and over||70 (61.4)||32 (28.1)||12 (10.5)||114 (41.3)|
|Female||101 (44.3)||72 (31.6)||55 (24.1)||228 (82.6)||p<0.001|
|Male||38 (79.2)||8 (16.7)||2 (4.2)||48 (17.4)|
|Married||100 (51.8)||53 (27.5)||40 (20.7)||193 (69.9)||p=0.676|
|Single||39 (47.0)||27 (32.5)||17 (20.5)||83 (30.1)|
|Having a child|
|Yes||94 (52.5)||48 (26.8)||37 (20.7)||179 (64.9)||p=0.523|
|No||45 (46.4)||32 (33.0)||20 (20.6)||97 (35.1)|
|Yes||35 (51.5)||16 (23.5)||17 (25.0)||68 (24.6)||p=0.412|
|No||104 (50.0)||64 (30.8)||40 (19.2)||208 (75.4)|
|Yes||34 (46.6)||24 (32.9)||15 (20.5)||73 (26.4)||p=0.670|
|No||105 (51.7)||56 (27.6)||42 (20.7)||203 (73.6)|
|Individuals over 65 years of age at home|
|Yes||23 (65.7)||7 (20.0)||5 (14.3)||35 (12.7)||p=0.151|
|No||116 (48.1)||73 (30.3)||52 (21.6)||241 (87.3)|
|COVID-19 diagnosis of self|
|Yes||24 (44.4)||16 (29.6)||14 (25.9)||54 (19.6)||p=0.501|
|No||115 (51.8)||64 (28.8)||43 (19.4)||222 (80.4)|
|COVID-19 diagnosis of a relative|
|Yes||98 (46.4)||66 (31.3)||47 (22.3)||211 (76.4)||p=0.06|
|No||41 (63.1)||14 (21.5)||10 (15.4)||65 (23.6)|
|Yes||87 (45.3)||65 (33.9)||40 (20.8)||192 (69.6)||p=0.001|
|Doesn’t remember||10 (40.0)||5 (20.09||10 (40.0)||25 (9.1)|
|No||42 (71.2)||10 (16.9)||7 (11.9)||59 (21.4)|
|Seasonal influenza vaccination|
|Regularly every year||39 (33.6)||44 (37.9)||33 (28.4)||116 (42.0)||p<0.001|
|Several times||77 (57.5)||34 (25.4)||23 (17.2)||134 (48.6)|
|Never had||23 (88.5)||2 (7.7)||1 (3.8)||26 (9.4)|
|Total||139 (50.4)||80 (29.0)||57 (20.7)||276 (100)|
*Column % ** The P-Value was calculated by Chi-square test
Suggestions regarding vaccination: 60.1% (n=166) of healthcare professionals considered COVID-19 disease as a threat to their health. 56.1% (n=155) of the participants thought that the COVID-19 vaccine would effectively prevent and control the disease. Moreover, the vaccine acceptance was 44.4% (n=24), and the vaccine rejection rate was 25.9% (n=14) in those with COVID-19 disease. One-third of those who recovered from the disease were undecided about whether or not to get the COVID-19 vaccine. Even if they have had the disease, 34.8% (n=96) wanted to be vaccinated. 52.9% of the participants (n=146) wanted all family members to be vaccinated (Table 2).
Table 2: Distribution of responses to recommendations regarding COVID-19 vaccine by vaccine intention
COVID-19 Vaccine Suggestions*
|n (%)||n (%)||n (%)|
|118 (76.1)||29 (18.7)||8 (5.2)||p<0.001|
|122 (51.3)||68 (28.6)||48 (20.2)||p=0.708|
|I know enough about the COVID-19 vaccine.||77 (68.1)||21 (18.6)||15 (13.3)||p<0.001|
|50 (39.7)||42 (33.3)||34 (27.0)||p<0.01|
|I am concerned about the long-term side effects of the vaccine||58 (33.0)||68 (38.6)||50 (28.4)||p<0.001|
|91 (94.8)||5 (5.29||0||p<0.001|
|110 (75.3)||19 (13.0)||17 (11.6)||p<0.001|
|112 (94.9)||6 (5.1)||0||p<0.001|
|127 (87.0)||15 (10.3)||4 (2.7)||p<0.001|
*Suggestions “Strongly Agree/Agree, Undecided, Disagree/ Strongly Disagree”.** The P-Value was calculated by Chi-square test.
Multivariate analysis was performed so that those who decided for vaccination as “no” and “undecided” were included in the same group. In the logistic regression model, male gender, being a doctor, and having a flu vaccine were independently correlated with vaccine acceptance (p<0.05) (Table3).
Table 3: Predictors of the intention to get COVID-19 vaccines among the participants (Binary Logistic Regression)
|Age||40 years and over (0)|
|Below 40 years of age (1)||0.784||0.438-1.402||0.412|
|Seasonal influenza||Yes, always (0)|
|Yes, Occasionally (1)||0.367||0.210-0.642||<0.001|
|I don’t remember (1)||2.969||0.972-9.072||0.056|
Abbreviations: OR: odds ratio, SE: standard error, CI: confidence interval, P: p-value.
*Those with “undecided” and “no” vaccination intentions were included in the same group.
According to our results, half of the family health center employees agreed to be vaccinated; one-fifth refused to be vaccinated, 30% of the employees were undecided about getting vaccinated. In studies regarding the vaccination intention of healthcare professionals to date, it is observed that the frequency of vaccination acceptance varies between 30% and 80% [5, 6]. In these studies, although being in contact with the patient increases the acceptance of vaccines in healthcare workers, there is no data on the healthcare field where the target population works. [5, 6]. In Turkey, the COVID-19 vaccination program is performed both in primary care family medicine units and in hospitals. Although being supported with regularly updated, easily accessible information helps healthcare professionals to establish their confidence in the vaccine and to guide the society, the absence of a COVID-19 algorithm or COVID-19 Guide specific to the primary healthcare services in the pandemic management process in the country, and the lack of a vaccine administration schedule may have increased the stress of family physicians and family health workers due to uncertainty regarding disease management processes and may have affected their confidence .
In our results, approximately 90% of health care professionals rated the risk of contracting COVID-19 as very high/high, and approximately one-third rated the risk of dying from the disease. Studies have indicated that the perception of disease risk can be a determinant in the attitudes of healthcare professionals to recommend and accept the vaccine and is even associated with believing that they are at high risk of receiving or transmitting the virus . Despite the high-risk perception rates regarding having and dying from the disease, about half of the participants did not consider the COVID-19 disease a threat to their health and thought that the vaccine would not be efficient in the course of the disease. However, since the beginning of the pandemic, at least one-fifth of all healthcare workers in Turkey is estimated to have been infected with the COVID-19 virus, and according to the report of the professional organization, nearly 500 healthcare workers died due to COVID-19 . The fact that a significant portion of healthcare workers who died five months following the initiation of the vaccination campaign was unvaccinated or that they did not receive an additional dose after two doses of the Sinovac vaccine also reveals the extent of vaccination hesitancy among healthcare workers in the country .
As a result of our study, age, gender, profession, and history of seasonal influenza vaccination were found asrelated factors in vaccine acceptance. Non-physician healthcare workers, women, and those under the age of 40 were less likely to accept to be vaccinated. The lower acceptance of women and nurses in vaccine hesitancy studies in healthcare workers during the pandemic is quite remarkable [34, 36, 38]. In addition, we found that a history of regular vaccination with seasonal influenza vaccine was not surprisingly a predictive factor in accepting COVID-19 vaccines. Not seeing the flu as a risk to their health and opinions that the vaccine would not work were the most prominent reasons for not getting the flu vaccine.
In conclusion, half of the primary care workers, one of the high-risk groups in the pandemic, were hesitant or refused to be vaccinated for COVID-19.Critical positive predictive factors for COVID-19 vaccination intention were male gender, physician, and having a history of vaccination with seasonal influenza vaccine. Knowing the factors affecting the vaccine acceptance of healthcare professionals can be considered as one of the most strategic moves in achieving the goal of high community vaccination rates. For evidence-based planning in vaccination studies, there is a need for studies to investigate the effective reasons for the acceptance of the COVID-19 vaccine by healthcare professionals at all levels.
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Conflict of Interest: None declared